Comparison of Clinical Outcomes of Endoscope-Assisted Technique and Conventional Surgery in Zone 2 Flexor Tendon Repair

PURPOSE

The purpose of the study was to compare clinical outcomes between patients who underwent endoscope-assisted flexor tendon repair and those who underwent conventional surgery.

METHODS

Patients were divided into 2 groups. Group 1 (endoscope-assisted surgery) included 21 patients (27 fingers) and group 2 (conventional surgery) included 19 patients (25 fingers). Outcomes assessed included the mean total active motion, Strickland classification, prevalence of rerupture, tenolysis requirement, and infection rate.

RESULTS

The mean total active motion was 152.3° in group 1 and 134.7° in group 2, which was significantly higher in group 1 compared to group 2. An excellent or good outcome was achieved in 25 (92.5%) of the fingers in group 1 as opposed to 17 (68%) fingers in group 2.

CONCLUSIONS

We conclude that endoscope-assisted surgery is an alternative method for tendon surgery, enables a minimally invasive approach, and provides a favorable range of motion.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Flexor Tendon Rupture Secondary to Gout

Extra-articular deposition of monosodium urate crystals is a widely recognized manifestation of gout. However, gouty infiltration of flexor tendons in the hand resulting in tendon rupture is exceedingly rare. This case report highlights a patient with gouty infiltration of flexor tendons in the right middle finger resulting in rupture of both the flexor digitorum profundus and flexor digitorum superficialis. Given the extent of gouty infiltration and need for pulley reconstruction, the patient was treated with two-stage flexor tendon reconstruction. Febuxostat was prescribed preoperatively to limit further deposition of monosodium urate crystals and continued postoperatively to maximize the potential for long-lasting results. Prednisone was prescribed between the first- and second-stage operations to prevent a gout flare while the silicone rod was in place. In summary, tendon rupture secondary to gouty infiltration is the most likely diagnosis in patients with a history of gout presenting with tendon insufficiency.

Flexor Tendon Attritional Ruptures Following Distal Radius Volar Plate Fixation

PURPOSE

To investigate patient and radiographic factors that may correlate with the time to flexor tendon rupture following volar plate fixation of distal radius fractures.

METHODS

A total of 31 patients who underwent volar plate removal because of flexor tendon rupture were analyzed. Patient demographics and the interval from operative fixation until rupture were determined retrospectively. Volar tilt and lateral carpal alignment were measured radiographically. The Soong classification was used to grade volar plate prominence. The correlation between the duration to tendon rupture and volar tilt, carpal alignment, and age was evaluated.

RESULTS

There were 7 men and 24 women. Mean age at the time of hardware removal and flexor tendon management was 66 years (n = 31). Radiographs were classified as Soong 1 (n = 24) and Soong 2 (n = 3). The mean measured volar tilt was -4° (range, -20°-+7°). The mean interval from operative fixation until complete tendon rupture was 4.9 years, (range, 0.3-13.1 years; n = 30). There was no correlation between the time interval to rupture and the magnitude of tilt, carpal alignment, or age at the time of operative fixation.

CONCLUSIONS

Although volar plate prominence was present in all patients with flexor tendon ruptures, radiographic parameters including the degree of dorsal tilt, lateral carpal alignment, and patient age did not correlate with the time interval from fixation to tendon rupture.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

The Outcomes of Flexor Tendon Injury Repair of the Hand: A Clinico-Epidemiological Study

Background and objective The incidence of flexor tendon injury is estimated to be 7-14 per 100,000 population. In India, such injuries are common and about 5% of these injuries require repair of the flexor tendon. In the present study, we share our experience of hand flexor tendon repair at a tertiary care center in western India. Material and methods Over a period of three years, 45 patients were admitted for tendon repair. After performing a proper evaluation, patients were taken for tendon repair. Primary outcome and secondary outcome parameters were assessed at the end of three months. Physiotherapy was continued for a longer duration in patients with movement restrictions. Data were compiled at each stage. Results The mean age of the patients was 28.84 years (range: 13-68 years) with a majority of the cases belonging to the age group 15-60 years. The majority of hand injuries were accidental (caused by work-related accidents, machine injuries, or animal bites) amounting to 80% (n=36), followed by assault cases (11%, n=5) and self-inflicted injuries, i.e., attempted suicides (around 9%, n=4). Among all injuries, the majority were in zone V (60%, n=27) followed by 24.4% (n=11) of cases in zone II. A few cases were in zone I, III, and IV (2.2%, 11.2%, and 2.2% respectively). The Buck-Gramcko scoring for primary injury was excellent with a recovery rate of 57.78%. Conclusion Flexor tendon injuries should be repaired with the aim of recovering strength as well as mobility. For optimal outcomes, total active motion protocol should be commenced immediately after the surgical repair. However, long-term physiotherapy may be required for attaining desired benefits.

Revision of Flexor Tendon Repair: Factors Associated With Flexor Tenolysis

BACKGROUND

Tenolysis restores mobility to the flexor tendon through the lysis of adhesions that inhibit and negatively impact functional outcomes following flexor tendon repair. Despite extensive literature on operative techniques and therapy protocols used to minimize adhesion formation, there are limited data examining the association of patient, injury, and postoperative factors with tenolysis. This study aims to: (1) quantify tenolysis rates following flexor tendon repair or reconstruction; and (2) identify patient demographic factors, medical comorbidities, injury characteristics, postoperative diagnoses, and complications associated with tenolysis.

METHODS

PearlDiver was used to identify patients who underwent a flexor tendon repair or reconstruction from 2010 to 2020. Patients were stratified by whether or not flexor tenolysis was performed. Patient demographics, comorbidities, injury characteristics, postoperative diagnoses, and complications were recorded. Logistic regression analysis was used to identify independent risk factors associated with tenolysis.

RESULTS

Database review identified 10 264 patients who underwent either flexor tendon repair or reconstruction, with 612 patients (6.0%) subsequently undergoing tenolysis. Logistic regression analysis determined that vascular injury preceding flexor tendon repair, surgical wound disruption, nerve injury diagnosed postoperatively, postoperative tendon rupture, and need for repeat flexor tendon repair were associated with an increased odds of tenolysis. Patient age, sex, and comorbidities were not associated with performance of tenolysis.

CONCLUSIONS

Although tenolysis rates may differ according to physician and patient preferences, identification of factors associated with tenolysis following flexor tendon repair allows surgeons to risk-stratify patients prior to surgery and help guide postoperative expectations if complications arise.

Incidence of Flexor Tendon Injuries in Complex Intra-Articular Distal Radius Fractures Fixed With Volar Rim Plate Osteosynthesis

Aim: The volar rim plate is anatomically contoured to provide buttressing of distal radius fragments including the lunate fossa. The low-profile design of the plate minimizes flexor tendon irritation. This study aims to determine the Disabilities of the Arm, Shoulder, and Hand (DASH) score and the presence of flexor tendon irritation at around one-year post operation.

Method: Between June 2020 and May 2021, all patients with AO-23B3 and AO-23C (1-3) distal radius fractures who were treated with a volar rim plate fixation were included in this study. At 12 months after surgery, the patients were evaluated utilizing DASH score as a routine as well as evidence of flexor tendon rupture or irritation.

Results: Twenty-five patients were finally included in this study. Of these, three required additional dorsal plating for dorsal subluxation, four required fixation of ulna styloid with tension band wiring, and the rest (18) had volar rim plate fixation in isolation. The mean DASH score was 16.3. Two of the patients had flexor tendon irritations; one in the middle finger and another in the ring and little finger. None had flexor tendon rupture.

Conclusion: The volar rim plate is designed to tackle complex intra-articular distal fractures which are near the watershed line. There was no evidence of flexor tendon irritation on routine follow-up. The outcome was satisfactory in this small series despite the complexity of the fractures. Evidence of flexor tendon irritation requires prompt attention to enable early implant removal.

Purulent Flexor Tendon Rupture of the Hand due to Mycobacterium abscessus Infection: A Case Report and Review of the Literature

Mycobacterium abscessus infection of the upper extremities is uncommon. However, M abscessus can cause severe chronic tenosynovitis, and delayed diagnosis may result in poor outcomes. We describe an unusual clinical case of purulent flexor tendon synovitis followed by subcutaneous tendon rupture due to M abscessus infection in a patient with diabetes mellitus. A 76-year-old man presented to our hospital with painful, erythematous swelling over his left fourth finger. On physical examination, the left fourth finger was swollen and reddish, with persistent exudate from the surgical scar. The left elbow was also swollen and reddish with persistent discharge, which was consistent with olecranon bursitis. The patient was unable to flex his left fourth finger, and the passive range of motion of the finger was also restricted. The physical examination findings and patient history suggested purulent flexor tendinitis. His infection healed after radical debridement of necrotic tissue and administration of antibiotics effective against M abscessus. Third-stage flexor reconstruction restored the function of the fourth finger. The combination of surgical debridement and chemotherapy was the most effective treatment for mycobacterial tenosynovitis. This case shows that M abscessus can cause chronic severe purulent tenosynovitis and flexor tendon rupture after tendon surgery. Although early diagnosis and combination treatment with debridement and chemotherapy might improve outcomes by limiting the severity and duration of damage to the flexor synovial system, late-presenting patients require combined radical debridement of necrotic tissue and aggressive chemotherapy followed by staged flexor tendon reconstruction.

Repair of Pronator Quadratus With Partial Muscle Split and Distal Transfer for Volar Plating of Distal Radius Fractures

Flexor tendon injury is a rare, but serious, complication after volar plate fixation for distal radius fractures. The plate position and prominence at the watershed line are contributing factors that cause flexor tendon injury. With the standard volar approach, the pronator quadratus (PQ) is typically elevated off the radial attachment. The distal part of the plate is often visible after repair of the PQ. We describe a "PQ-splitting" technique for covering the distal edge of the plate if primary PQ repair cannot completely cover the distal part of the plate. We also report the outcome of our series. This method can potentially prevent direct gliding of flexor tendons on the distal part of the plate and prevent flexor tendon attrition on the plate prominence.

Risk Assessment of Tendon Attrition Following Treatment of Distal Radius Fractures With Volar Locking Plates Using Audible Crepitus and Placement of the Plate: A Prospective Clinical Cohort Study

PURPOSE

To identify risk factors for tendon attrition after volar locking plate fixation of distal radius fractures.

METHODS

We prospectively assessed attrition of the flexor pollicis longus tendon at volar plate removal in 127 hands in 126 patients. We also evaluated preoperative lateral wrist radiographs, sonographs, and crepitus with flexor pollicis longus tendon motion and compared the demographic and radiographic characteristics of patients with and without tendon attrition. Multivariate logistic regression analysis was employed to identify the factors independently associated with tendon attrition.

RESULTS

We found 12 cases of tendon attrition (10%) and 1 that presented with tendon rupture in our cohort. Crepitus was recognized in 14 patients (11%): 6 cases (50%) were among the 12 hands in 12 patients with tendon attrition whereas 8 (7%) were detected in the remaining 114 hands in 113 patients. Logistic regression examination revealed that audible crepitus and volar placement of the plate in lateral radiographs were independent predictors of tendon attrition.

CONCLUSIONS

Crepitus and volar placement of hardware in lateral radiographs were independent risk factors for flexor tendon attrition after volar plating for distal radius fracture. These results may facilitate surgical decisions regarding early plate removal to prevent possible tendon rupture.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Danger zones for flexor tendons in volar plating of distal radius fractures

PURPOSE

To define a danger zone for volar plates using magnetic resonance imaging by analyzing the position of the flexor tendons at risk around the watershed line.

METHODS

We analyzed 40 wrist magnetic resonance images. The location of the flexor pollicus longus (FPL) and index flexor digitorum profundus (FDPi) tendons was recorded at 3 and 6 mm proximal to the watershed line of the distal radius. We measured the distance between the volar margin of the distal radius and the FPL and FDPi tendons, and the coronal position of the tendons.

RESULTS

At a point 3 mm proximal to the watershed line, FPL and FDPi were located on average 2.6 and 2.2 mm anterior to the volar margin of the distal radius. This distance increased to 4.7 and 5.3 mm at a point 6 mm proximal to the watershed line. The FPL and FDPi were located at 57% and 42% of the total width of the distal radius from the sigmoid notch at 3 mm from the watershed, and at 66% and 46% at 6 mm from the watershed.

CONCLUSIONS

Surgeons should be aware of the close proximity of the flexor tendons to the volar cortex of the distal radius proximal to the watershed line and their radial to ulnar position. Three millimeters proximal to the watershed line, plate placement more than 2 mm anterior to the volar cortex or the use of plates thicker than 2 mm poses a high risk for directly contacting flexor tendons.

CLINICAL RELEVANCE

This article may prove to be helpful in avoiding flexor tendon injury during volar plate fixation.

Distal radius volar locking plate design and associated vulnerability of the flexor pollicis longus

PURPOSE

Flexor pollicis longus (FPL) tendon rupture is a well-documented complication related to the use of distal radius volar locking plates (VLPs). The final common pathway of flexor tendon rupture appears to involve implants prominent at the watershed line. We hypothesized that significant differences in VLP prominence exist between various plate designs.

METHODS

Ten fresh frozen specimens were dissected to identify the path of the FPL in relationship to the distal radius at the watershed line. Five VLP designs were fixed to each specimen based on their anatomic fit, and slid distally until the distal edge of the plate reached the watershed line. The position of each fixed plate was evaluated by fluoroscopy. We used a 3-dimensional laser scanner to create computer models. The total surface area of plate prominence volar to the watershed line and the prominent area beneath the FPL were measured in the axial plane using computer software.

RESULTS

At the watershed line, the FPL was located at 54% of the maximal width of the radius, as measured from its volar-ulnar corner. There were no significant differences in the location of plate fixation on lateral view radiographs according to the classification of Soong et al. The mean total surface area of plate prominence was 36 mm(2). The mean prominent area beneath the FPL was 10 mm2. Significant differences in plate prominence were noted for various designs.

CONCLUSIONS

Despite optimal plate placement, various VLP designs were observed to have prominent profiles volar to the watershed line, to varying extents.

CLINICAL RELEVANCE

The results raise concerns regarding interference between all of the analyzed VLP designs and the FPL. This study may help guide both implant design considerations and assist the surgeon in better understanding implant morphology as it relates to iatrogenic flexor tendon injury.

Results of pronator quadratus repair in distal radius fractures to prevent tendon ruptures

BACKGROUND

Distal radius fractures are one of the the most common adult fractures encountered during the clinical practice of an orthopedic surgeon.12 Although several methods of treatment are suggested for these fractures, there are still controversies about the best treatment approach in the literature. Volar plating of distal radius fracture is a method of treatment which has become increasingly popular. One of the complications of this technique is flexor tendon rupture. The purpose of this study was to evaluate the protectiveness of complete repair of pronator quadratus muscle against flexor tendon rupture.

MATERIALS AND METHODS

From September 2010 to September 2012, a consecutive series of 157 patients who were younger than 60 years with unstable distal radius fractures were included in the study. A standard volar approach to the distal radius was carried out. The radial and distal ends of pronator quadratus muscle were meticulously elevated from the radius and after volar plate fixation of the fracture, pronator quadratus muscle was restored to its normal insertion. We achieved full coverage of the plate with this muscle and followed the patients postoperatively.

RESULTS

A total of 135 patients were studied. The mean age of patients was 34 ± 10 years (range 20-60 years). One 55-year-old diabetic female patient with flexor tendon rupture was identified. The flexor pollicis longus tendon had ruptured 16 months after surgery.

CONCLUSIONS

Pronator quadratus repair should be done in distal radius fracture to protect flexor tendons.

Rupture of flexor tendons as a complication of a distal radius fracture

Two cases are reported of flexor tendon rupture of ulnar side fingers as a complication after distal radius fracture. One was associated with a prominent distal volar lip of fracture site, the other with a relatively volarly displaced ulnar head due to the dorsally tilted distal radius due to malunion. These may be unique cases of flexor tendon rupture with conservatively treated patients.

Phaeohyphomycosis infection leading to flexor tendon rupture: a case report

A rare previously unreported cause of flexor tendon rupture is described. A 66-year-old man presented with a fully extended left middle finger, accompanied by swelling and purulent drainage. Prior to presentation, he had received a steroid injection for left middle finger stenosing tenosynovitis and subsequently developed culture-proven phaeohyphomycosis fungal infection and secondary enterococcal bacterial infection, requiring pharmacotherapy and incision, drainage, and debridement for abscess formation. Clinical and magnetic resonance imaging findings were consistent with the diagnosis of closed flexor tendon rupture of the left middle finger. Antifungal and antibiotic therapy followed by two-stage flexor tendon reconstruction was performed. Six months postoperatively, full passive range of motion was achieved and the proximal interphalangeal and distal interphalangeal joints of the left middle finger actively flexed to 125 degrees and 90 degrees, respectively.

Botulinum toxin use as an adjunctive modality in a patient with multiple flexor tendon ruptures

Botulinum toxin A has been described in treatment protocols for several disease processes, from primary axillary hyperhydorosis to esophageal dysfunction. It is best known for its use in plastic and dermatological practices. Botulinum toxin has a straightforward mechanism of action. The toxin inhibits acetylcholine release at the neuromuscular junction causing a chemical denervation, which ceases contractions of the muscle. With its minimal side effect profile, botulinum toxin should be considered when muscle spasm is a detriment. This case involves an injury to the hand of a patient with a history of intermittent diffuse muscle spasms. Subsequently, due to the patient's previous upper extremity muscle spasms, repeated flexor tendon repair ruptures of the index finger occurred until botulinum toxin was administered to the offending muscle. The patient has not required any additional surgical interventions for the repaired tendon and is now actively flexing all digits. This case report demonstrates how botulinum toxin can be used in a clinical scenario when decreased muscle activity is desired to promote tendon healing.